Key words
small saphenous vein - saphenopopliteal junction - saphenopopliteal recurrence - junction
anomalies
Schlüsselwörter
Vena saphena parva - Parvakrosse - Rezidivvarikose der V. saphena parva - Mündungsanomalien
Approximately 350 000 procedures are carried out on the epifascial venous system each
year, of which some 10–19 % entail surgery of the saphenopopliteal junction (SPJ);
the figure in our own patients is 15 %. We recently described these patients in detail
in a review article published in the medical journal Phlebologie [28]. According to Hach [10], involvement of the small saphenous vein (SSV) compared with the great saphenous
vein (GSV) is in a ratio of 1:6. Women are affected twice as frequently as men. The
left leg is involved slightly more often [8] ([Fig. 1]).
Fig. 1 Impressive robust trunk varicose vein of the small saphenous vein in the left leg.
The subfascial course to the saphenopopliteal junction is indicated with a coloured
marker.
Open flush ligation of the small saphenous vein
Open flush ligation of the small saphenous vein
High ligation of the great saphenous vein (GSV) as Hach stipulated in his definition
of ‘crossectomy’ – “removal of the trunk vein flush with its opening into the deep
vein and resection of the proximal segment after dissection of all small tributary
veins opening around the saphenofemoral junction” – is always possible. There are
no exceptions or anatomical reasons to prevent such a procedure. No matter how short
it is, a stump left behind after high ligation is a technical error and often the
cause of recurrent varicose veins. The German study on inguinal recurrence provided
firm evidence for this [18].
In this way, Mumme et al. underpinned the old saying of G. Salzmann, a long-serving
consultant under Prof. Hach, namely that recurrent varicose veins are not due to inherited
venous incompetence but rather to the surgical skill that has not been acquired ([Fig. 2], [3]).
Fig. 2 Correctly performed high ligation of the great saphenous vein (GSV). The ligature
lies flush with the deep vein.
Fig. 3 Redo high ligation with residual GSV stump. Clear technical error during the first
operation. No neovascularisation!
Despite this clear requirement, the basic principles of a proper flush ligation have
not been observed in many cases, especially in the English-language literature, as
we have repeatedly demonstrated [11]
[28]
[29]. Unlike the procedure for high ligation of the great saphenous vein, there are no
generally recognised guidelines for small saphenous varicose veins with respect to
their treatment at the junction with the deep vein. Hach and Mumme [10] described flush ligation of the small saphenous vein as the amputation of the small
saphenous vein directly at its opening into the popliteal vein, together with any
necessary ligation of the muscle veins ([Fig. 4], [5]).
Fig. 4 Diagram of the surgical site in the popliteal fossa.
Fig. 5 Correctly performed flush ligation of the small saphenous vein, with ligation of
the gastrocnemius veins draining at the saphenopopliteal junction.
In addition to the flush ligation of the small saphenous vein recommended by Hach
and Mumme, current guidelines on the treatment of varicose veins [2] also include modified high ligation as close to the saphenopopliteal junction as
possible. The reason for this option is that, according to the guidelines, a flush
ligation is not always possible. This is a thoroughly worthwhile addition to the specifications
of Hach and Mumme.
The guidelines recommend the use of non-absorbable sutures, as was found to be the
case in a survey of varicose vein surgeons in Germany, Austria, and Switzerland twenty
years ago [15]. The experts who drew up the guidelines considered the use of non-absorbable sutures
to be the simplest and most cost-effective means of preventing recurrence after high
ligation of both the great and the small saphenous veins [16]
[23]. Hach and Mumme [10] also recommended a double ligature with non-absorbable suture material for flush
ligation of the small saphenous vein. The wide range of anatomical variation at the
saphenopopliteal junction, with the small saphenous vein draining into the deep vein
on the anterior or posterolateral aspect, is one reason why flush ligation of the
small saphenous vein is not performed in all cases [13]
[14]
[33]. In a few exceptional cases, therefore, the current guidelines consider modified
high ligation of the small saphenous vein close to the junction to be safer with fewer
side effects. This applies both to anomalies of the saphenopopliteal junction and
to the topographical features of the motor nerves in the popliteal fossa. Before risking
injury to the deep vein or a motor nerve by forcing a flush ligation of the small
saphenous vein, we consider a modified high ligation close to the junction to be more
expedient and associated with fewer side effects. However, the rate of flush ligations
increases proportionately to the surgeon’s experience [28]. In a not-inconsiderable number of cases, flush ligation of the small saphenous
vein is made more difficult by the muscle veins draining into the saphenopopliteal
junction. In his reference work ‘Phlebography of the leg and pelvic veins’ [8] Hach states that the small saphenous vein and gastrocnemius veins drain into the
popliteal vein in a common trunk in 32 % of cases. Tying off the muscle veins by placing
a ligature on the small saphenous vein flush with the popliteal vein would block the
blood flow from the gastrocnemius veins, even without ligating them directly. In a
small cohort study of 55 patients, we observed the gastrocnemius veins draining directly
at the saphenopopliteal junction in 38 % of cases, analogous to the 32 % reported
by Hach [30].
Fourteen days after ligation of these muscle veins, we found thrombosis in only 6 %
of the gastrocnemius veins that has been tied off. Ectasia and the thin walls of the
gastrocnemius veins are amongst the reasons why the proper flush ligation of the small
saphenous vein is such a challenging surgical procedure that demands great experience
on the part of the surgeon [10].
Problems that may arise in open flush ligation of the small saphenous vein are shown
in [Table 1].
Table 1
Problems in small saphenous vein surgery.
|
high opening
|
|
intersection of motor nerves running immediately across the saphenopopliteal junction
|
|
anterior opening
|
|
multiple openings of the SSV
|
|
reduced calibre of the lateral popliteal fossa perforator close to the junction
|
|
gastrocnemius veins draining at the saphenopopliteal junction
|
|
gastrocnemius incompetence with the clinical picture of short saphenous varicose veins
|
Preoperative diagnostic investigation
Preoperative diagnostic investigation
Each surgical procedure on the small saphenous vein must be preceded by meticulous
diagnostic imaging. In most cases today, this entails duplex ultrasound scanning,
ascending venography with a Vasalva manoeuvre only seldom being required, and possibly
being supplemented by varicography [8]. Hach performed his greatest service by demonstrating the different anatomical variants
of the saphenopopliteal junction on venography, thus allowing the first surgical procedures
targeted to the origin of the reflux (Hach’s recirculation circuit) [9] ([Fig. 6], [7], [8]).
Fig. 6 Venogram showing the saphenopopliteal junction: classical situation at the opening.
The gastrocnemius vein drains separately into the popliteal vein at a more distal
location.
Fig. 7 Venogram showing the saphenopopliteal junction: atypical double opening.
Fig. 8 Venogram showing the saphenopopliteal junction: completely atypical opening; the
arrow indicates the opening of the small saphenous vein into the popliteal vein. The
centimetre grid helps to guide the incision during surgery.
Duplex scans today do not give the topographical overview of the anatomy in the same
way as the more clearly depicted images obtained by venography. However, it is indisputable
that duplex ultrasound scanning has now replaced venography ([Fig. 9]).
Fig. 9 Duplex ultrasound scan of the saphenopopliteal junction: gastrocnemius vein draining
into the small saphenous vein.
In his reference work ‘Vein surgery’, Hach gave precise descriptions and exact frequencies
of the different levels at which the small saphenous vein drains into the deep venous
system [10]. Our own investigations of the saphenopopliteal junction also using venography with
a Valsalva manoeuvre showed that the small saphenous vein opens into the popliteal
vein 2–5 cm above the radiological knee joint line in about 50 % of cases [31]. In another approximately 30 %, the opening lies 5–8 cm above the joint line. There
are also anterior openings, posterolateral openings, junctional aneurysms, and sometimes
gastrocnemius veins with ectatic changes draining at the saphenopopliteal junction
([Table 2]).
Table 2
Anatomical variants of the saphenopopliteal junction seen on ascending venography
with a Valsalva manoeuvre, according to Hach.
|
level of the saphenopopliteal junction
(n = 127)
|
saphenopopliteal junction abnormalities
(n = 140)
|
|
below the knee joint line
|
n = 0 (0.0 %)
|
ventral opening
|
n = 10 (7.1 %)
|
|
up to 2 cm above
|
n = 7 (5.6 %)
|
lateral opening
|
n = 22 (15.7 %)
|
|
2–5 cm above
|
n = 66 (52.4 %)
|
aneurysm
|
n = 20 (14.1 %)
|
|
5–8 cm above
|
n = 42 (33.3 %)
|
|
|
|
8–11 cm above
|
n = 8 (6.3 %)
|
|
|
|
11–15 cm above
|
n = 1 (0.8 %)
|
|
|
|
15–20 cm above
|
n = 1 (0.8 %)
|
|
|
|
more than 20 cm above
|
n = 1 (0.8 %)
|
|
|
|
no information
|
n = 13 (9.3 %)
|
|
|
The most common finding was an acute-angled saphenopopliteal junction situated about
3–4 cm above the knee joint line. But very tortuous anomalies at the junction with
siphon- or double-siphon-like openings of the small saphenous vein were also observed
([Fig. 10]).
Fig. 10 Ultrasound scan of a small saphenous vein with syphon-like opening.
Preoperative duplex scans are carried out with the patient standing with a slightly
bent knee. These investigations should be performed by the surgeons themselves. The
precise level of the junction can easily be indicated by small pressure markings with
a ballpoint pen. Both the course of the small saphenous vein and the level at which
it opens into the popliteal vein can then be indicated on the leg with a coloured
marker. In addition to duplex ultrasound scanning, we also perform preoperative peripheral
venous pressure measurements (phlebodynamometry) ([Fig. 11]).
Fig. 11 The pressure curve returns to normal after compression of the proximal small saphenous
vein (mk = with compression; ok = without compression).
Only when these functional diagnostics show that the venous haemodynamics return to
normal once the pathological recirculation circuit described by Hach has been interrupted
manually do we consider that there is an indication for active intervention. We do
not consider duplex scanning alone to be a sufficient criterion for surgery!
Surgical technique
The operation is to be carried out with the patient lying prone and with the knee
bent at an angle of 30° [10]
[28].
With combined procedures on the great and small saphenous vein territories, the patient’s
position has to be altered during the operation. It is more difficult to perform a
flush ligation of the small saphenous vein correctly when the patient is in a lateral
or supine position with the leg elevated, and there is a higher associated risk of
injury to adjacent structures; these positions should therefore be avoided!
The results of the retrospective small saphenous vein study cited below refer solely
to surgery performed with the patient in the prone position. We have recently described
the precise details of the surgical technique [28]. The transverse incision in the popliteal fossa must be sufficiently large, depending
on the local anatomy, the presence of junctional anomalies, the level of the saphenopopliteal
junction in relation to the knee joint, and how thick the leg is. Obtaining a good
surgical view takes priority over leaving a small scar! If the incision is too small
it diminishes the overview, increases the surgical risk, and is associated with a
higher risk of recurrence [10].
Open flush ligation of the small saphenous vein requires a dry surgical field. Injuries
to the blood vessels must be avoided. Saphenopopliteal surgery requires a delicate
touch. Self-retaining retractors should not be used because of the risk of injury
to nerves and thin-walled veins (gastrocnemius veins, ectatic saphenopopliteal junction).
We have found that four hands are needed (2 × Roux retractors and 2 × Langenbeck retractors),
which means that we need a team of two scrub nurses or one scrub nurse and a surgical
assistant. Injury to the motor nerves must always be considered a possibility with
a flush ligation of the small saphenous vein, and particularly with redo surgery for
recurrence [28]. We therefore look specifically for the tibial nerve, free up a long segment and
displace it carefully to the side with a Langenbeck retractor or, better still, with
a wide silicone loop (vessel loop), as far as necessary for us to be able to tie the
ligature flush with the popliteal vein.
We adhere closely to the surgical maxim ‘what I can see, I don’t damage’. The robust
tibial nerve lies in the middle of the surgical field, often directly on the roof
of the popliteal vein. It lies medially to the small saphenous vein in 54 % of cases,
and laterally in 51 % of cases [17]. The peroneal nerve only has to be identified when the small saphenous vein terminates
very laterally in the popliteal vein but then also has to be freed very carefully
over a long segment. The peroneal nerve is a ‘sensitive plant’ which takes any pulling
or pushing amiss. You can look at it but must not grasp it with forceps. The peroneal
nerve has to be very carefully, cautiously, and gently dissected out and equally carefully
displaced to the side. The saphenopopliteal junction sometimes lies directly beneath
the y-shaped fork where the sciatic nerve divides into the peroneal nerve and the
tibial nerve ([Fig. 12], [13], [14]).
Fig. 12 Surgical site in the popliteal fossa; proximity of the tibial nerve (N. tib.) to
the small saphenous vein (VSP).
Fig. 13 Surgical field showing the small saphenous vein, saphenopopliteal junction, and motor
nerves (VSP = small saphenous vein, N. tib = tibial nerve, N. peron = peroneal nerve,
V. popl. = popliteal vein).
Fig. 14 Surgical field showing the small saphenous vein, saphenopopliteal junction, and motor
nerves (VSP = small saphenous vein, N. tib = tibial nerve, N. peron = peroneal nerve,
V. popl. = popliteal vein).
In these cases, the three nerves have to be identified and a long segment meticulously
exposed. Without pulling or tension, the small saphenous vein can then be displaced
medially or laterally below the nerve, depending on the anatomical situation. The vein
is moved until the saphenopopliteal junction can be identified conclusively and dissected
out carefully to allow ligation of the small saphenous vein flush with the deep vein
([Fig. 15]).
Fig. 15 Correct flush ligation of the small saphenous vein (VSP = small saphenous vein, N.
tib = tibial nerve, N. peron = peroneal nerve, V. popl. = popliteal vein).
Any pressure or pulling on either of the two nerves, especially the peroneal nerve,
should be avoided. The gentlest approach is to displace the nerves with a wide silicone
loop, but sometimes a narrow Langenbeck retractor has to be used. The tibial nerve
is ‘robust’. In approximately 6000 flush ligations of the small saphenous vein, we
have never seen an injury or pressure-induced damage of the tibial nerve. Nevertheless,
there were three instances of transient pressure-induced damage to the peroneal nerve
in our patient population. Function was restored completely in all three cases, although
it took nearly a year until the foot drop finally disappeared in a very muscular scuba
diver.
In his standard work ‘Vein surgery’ [10], Hach referred to the patient population of a 1983 study [12], in which Helmig also saw three cases of transient peroneal lesions in 1094 open
flush ligations of the small saphenous vein.
The indications for redo surgery must be carefully considered, particularly in the
popliteal fossa following incomplete high ligation leaving short or very short stumps,
or in the case of technically demanding operations for neoangiogenesis after previous
first-time surgery. Possible improvements in the venous haemodynamics, as shown by
preoperative phlebodynamometry, have to be weighed up carefully against the surgical
risks. In individual cases, it may be better not to re-operate and instead use foam
sclerotherapy as the treatment of choice for the patient. Demonstrable mild saphenopopliteal
junction reflux in the popliteal fossa should not automatically induce the surgeon
to carry out a revision! Ligation of the small saphenous vein is one of the most demanding
procedures in vein surgery. There is an inherent risk of major complications, as well
as vascular and motor nerve injuries.
Correctly determining the indication for revision surgery therefore has absolute priority.
In accordance with Hach’s recommendations [9], prepopliteal stump ligation is the only redo surgery for saphenopopliteal recurrence
that we perform ([Fig. 16]).
Fig. 16 Venography with Valsalva manoeuvre after Hach. Recurrent small saphenous varicose
veins with a short small saphenous vein stump.
Redo surgery is always carried out in an inpatient setting. Despite or perhaps even
because of our own great experience, we consider that it is not acceptable for this
procedure to be carried out on an ambulatory basis, even if our colleagues from the
medical service of the health insurance companies (MDK) sometimes think otherwise.
Surgeons who are experienced in small saphenous vein surgery are rare, and they are
even more rarely to be found in the MDK.
Besides the strict determination of the indication, redo surgery at the saphenopopliteal
junction requires an experienced surgeon, two assistants (or two scrub nurses) and
a specific set of surgical instruments, including small vascular clamps, a Baby-Satinsky
clamp, etc. However, the use of these instruments should be avoided whenever possible.
Projectile venous bleeding that immediately obscures the view can be dealt with less
traumatically by gentle finger pressure or with surgical cotton buds held above and
below the source of bleeding, then placing interrupted 5–0 or 6–0 vascular sutures.
A strong jerky approach as for arterial surgery is contraindicated.
Nevertheless, when pressure is being applied by a finger or cotton bud above and below
the bleeding source, the space in the popliteal fossa available for suturing may be
very limited. It is therefore difficult to perform a vascular suture. In these circumstances,
we have found the following procedure to be of value:
Bleeding is stilled by applying several layers of scrunched-up compresses and then
a Löfqvist cuff, which is rolled on as far as the mid-thigh and then fixed in place
with metal brakes ([Fig. 17]).
Fig. 17 Löfqvist cuff with metal brake, after R. Fischer.
Even though minimal bleeding remains in the popliteal fossa, there is a clearer view
and the vascular suture is much easier to perform. On no account must there be any
suture cerclage, blind clamping or bulk ligation! In emergency situations during flush
ligation or redo surgery of the small saphenous vein, the basic principles of Pschyrembel
and especially of Hach [10] must be remembered, namely to keep calm and radiate calm, so that the subsequent
surgical steps required can be considered quietly, planned properly, and then carried
out without a rush.
Cohort study on flush ligation of the small saphenous vein
Cohort study on flush ligation of the small saphenous vein
Our cohort study included 153 patients. Of the 187 surgically treated legs, 138 (74 %)
were in women and 49 (26 %) in men. The study examined and included all patients who
routinely attended the Saarlouis Vein Centre in 2016 and had undergone flush ligation
of the small saphenous vein at the Centre during the previous years.
The aim of the study was to determine the duplex ultrasound findings in the treated
popliteal fossa. The optimal result was the absence of a small saphenous vein stump,
neovascularisation, or any other pathological findings at the saphenopopliteal junction.
Pathological findings were divided into the following groups:
-
Small saphenous vein stump, clinically relevant
-
Neovascularisation, clinically relevant
-
Small saphenous vein stump or neovascularisation, not clinically relevant
-
Recurrent varicose veins in the treated popliteal fossa, but with new openings, clinically
relevant
Results
In the follow-up of the 187 treated legs, the operation had been carried out 1 to
5 years previously in 84 cases, 6 to 10 years previously in 82 cases, and 11 to 19
years previously in 21 cases.
We found a small saphenous vein stump with clinically relevant recurrent varicose
veins in 4 patients (2.1 %); the length of the stump ranged from 3 mm to 10 mm. Neovascularisation
with clinically relevant recurrent varicose veins was present in two patients (1.1 %).
Duplex ultrasound scans showed a stump or neovascularisation without clinical evidence
of recurrent varicose veins in three patients (1.6 %). We also found completely new
sites of incompetence in the popliteal fossa, clearly distant from the first treated
site, in six patients (3.2 %). These last findings were not counted as recurrences.
Between the first and second intervention, the level of the opening into the deep
vein differed completely by 3–5 cm. The reason for this may be that the first operation
dealt with the small saphenous vein, while the redo surgery concerned a lateral perforator
in the popliteal fossa, or vice versa. These are, however, rare isolated cases.
The rate of true saphenopopliteal junction recurrences, with or without clinical signs
was 4.8 % ([Table 3]).
Table 3
Duplex ultrasound scanning evidence of recurrence after small saphenous vein surgery.
|
recurrence
|
number
(187)
|
percentage
(%)
|
|
|
clinically relevant with stump
|
4
|
2.1 %
|
3–4.1–5.9–10.1
(stump length in mm)
|
|
clinically relevant with neovascularisation
|
2
|
1.1 %
|
|
|
clinically not relevant with stump/neovascularisation
|
3
|
1.6 %
|
Σ 4.8 %
|
|
clinically relevant with new opening
|
6
|
3.2 %
|
|
|
total
|
15
|
8 %
|
|
|
true recurrences
|
9
|
8 %–3.2 % = 4.8 %
|
|
Discussion
The research presented here in no way meets the criteria for a proper scientific study.
The 187 legs followed-up over a period going back 19 years came from about 3800 operations
on the small saphenous vein, while figures for the 166 legs going back 10 years were
taken from about 2000 operations. The exact follow-up rate in relation to the number
of operations carried out is therefore very small, and considerably less than 10 %.
The data do, however, give an idea of the activities being carried out in the setting
of a practising phlebologist.
After an average of 4 years’ follow-up, the findings of the two cohort studies were
as follows [31]: in the older study conducted in 1995 we found the recurrence rate at the saphenopopliteal
junction to be 10 %, with evidence of a small saphenous vein stump in 14 %. The second
study carried out 12 years later showed pathological findings at the junction in 3 %,
with a residual stump in 7 % [31]. Due to increasing surgical experience, the saphenopopliteal junction recurrences
decreased because the incidence of a residual stump had halved.
Results of small saphenous vein surgery published in the literature are unsatisfactory
([Table 4]). Nevertheless, it must be remembered that the available studies do not use a standardised
surgery technique and their definitions of recurrence are very different [32]. The high rates of small saphenous vein stumps are evidence that the saphenopopliteal
ligation was not performed properly. All possible variations are represented, from
a simple subfascial ligation [5]
[6] to a true flush saphenopopliteal ligation [27]
[31]
[34]. Allegra et al. [1], with a saphenopopliteal junction recurrence rate of 30 % after five years, gives
no details at all of the surgical technique. The high recurrence rate, however, suggests
that the flush ligation was not performed correctly, even though the authors talk
of ‘stripping of the small saphenous vein from the saphenopopliteal junction to the
lateral malleolus’. This once again shows the discrepancy between rhetoric and reality
with respect to the proper flush ligation of the small saphenous vein. This discrepancy
was also reflected in the work by Winterborn et al. 2004 [35]. Rebecca Winterborn, a co-worker of the renowned British vein surgeon Jonathan Earnshaw,
asked 379 vascular surgeons in Great Britain and Ireland about their routine practice
for open flush ligation of the small saphenous vein. 11.5 % of those questioned declined
to operate on small saphenous varicose veins at all, because of the risk of nerve
injury. Only about 50 % carried out preoperative duplex ultrasound scans. 20 % did
not operate with the patient lying prone. 13 % still performed a direct subfascial
ligation in the same way as Feuerstein had done 40 years before [5]. 76 % placed the ligature around the small saphenous vein somewhat more deeply,
but where? Precise details of the ligature’s position were lacking. Only 10 % of surgeons
performed open flush ligation of the small saphenous vein in line with the recommendations
made by Hach and Mumme, after properly exposing the saphenopopliteal junction. O’Hare
et al. [21], from the Winterborn and Earnshaw research group, reported a retrospective multicentre
study in the United Kingdom, in which saphenopopliteal junction disconnection and
stripping were compared with saphenopopliteal junction disconnection alone. One year
later, duplex ultrasound showed recurrence in 13 % of the SPJ disconnection/stripping
group and in 32 % of those who had undergone SPJ disconnection alone. As in the publication
by Allegra et al., these authors talked of ‘saphenopopliteal junction ligation’ [1]. It makes us wonder, however, as Winterborn et al. stated that only 10 % of British
surgeons actually expose the popliteal vein. Once again, we have reasonable doubts
about the accuracy of use of the terms ‘flush ligation’, ‘high ligation’ and ‘saphenopopliteal
ligation’ in the same way as for procedures at the saphenofemoral junction [11]
[28]
[29].
Table 4
Overview of the literature. Recurrence rate after small saphenous vein surgery.
|
high ligation and stripping of the small saphenous vein
|
|
|
year
|
author
|
n
|
follow-up
|
recurrence
|
|
1996
|
Tong
|
70
|
|
61 %
|
|
1999
|
Hanzlick
|
41
|
5 years
|
|
|
2001
|
Vin
|
77
|
9.2 years
|
68 %
|
|
2003
|
Pukacki
|
42
|
4.9 years
|
78 %
|
|
2007
|
Allegra
|
132
|
5 years
|
30 %
|
|
1995
|
Stenger
|
140
|
3.75 years
|
10 %
|
|
2007
|
Stenger
|
137
|
4.5 years
|
3 %
|
|
2006
|
Hartmann
|
25
|
14 years
|
12 %
|
|
2012
|
Samuel
|
50
|
1 year
|
0 %
|
Other authors, such as O’Donnell et al. [20], are more critical of saphenopopliteal ligation. They are of the opinion that the
risk of postoperative complications increases with the extent of dissection around
the saphenopopliteal junction. Rashid et al. [24] provided evidence that, despite preoperative duplex imaging, the saphenopopliteal
junction was not exposed during 22 % of operations and a flush ligation was not achieved
in 59 %. Even in the three randomised controlled trials so far available, in which
ligation and stripping of the small saphenous vein was compared with endoluminal treatment
methods, flush ligation of the small saphenous vein was obviously not performed [3]
[19]
[26]. We have recently published details of these RCTs [28]. In summary, we can say that the principles of a proper flush ligation of the small
saphenous vein, as described by Hach and Mumme in their handbook and as they appear
in the current guidelines of the German Society of Phlebology, have not been respected
– especially in the literature of English-speaking countries. Nor is surgery performed
according to these criteria in those parts of the world. On the other hand, the data
we have presented above can at least be considered evidence that the observance of
Hach’s recommendations on saphenopopliteal ligation leads to a low recurrence rate
which more or less corresponds to that of high ligation of the great saphenous vein
[22]
[23]
[25]
This article was written to honour the occasion of Professor Wolfgang Hach’s 90th birthday. It was he who developed German phlebology from pragmatic practice-oriented
therapy to a scientifically based medical specialty.
